Provider Demographics
NPI:1194598425
Name:GRATAMA JACKSON, BRIANNA MARIA (OTD, OTR/L)
Entity type:Individual
Prefix:
First Name:BRIANNA
Middle Name:MARIA
Last Name:GRATAMA JACKSON
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:BRIANNA
Other - Middle Name:MARIA
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10147 KINGSBRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-1828
Mailing Address - Country:US
Mailing Address - Phone:813-728-2191
Mailing Address - Fax:
Practice Address - Street 1:2370 BRUCE B DOWNS BLVD
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544-9214
Practice Address - Country:US
Practice Address - Phone:813-973-1033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-30
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24704225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist